Abstract

Nurses working in the Neuro-Intensive Care Unit at Aarhus University Hospital lack the tools to prepare children for the alarming atmosphere they will enter when visiting a hospitalised relative. The complex soundscape dominated by alarms and sounds from equipment is mentioned as the main stressor. As a response to this situation, our design artefact, the interactive furniture Kidkit, invites children to become accustomed to the alarming sounds sampled from the ward while they are waiting in the waiting room. Our design acknowledges how atmospheres emerge as temporal negotiations between the rhythms of the body and the environment in conjunction with our internalised perception of the habituated background. By actively controlling the sounds built into Kidkit, the child can habituate them through a process of synchronising them with her own bodily rhythms. Hereby the child can establish, in advance, a familiar relationship with the alarming sounds in the ward, enabling her to focus later more on the visit with the relative. The article discusses the proposed design strategy behind this solution and the potentiality for its use in hospital environments in general.

1. Introduction

Many parents are, certainly, fearful of bringing their children here, and they are not pleased to do it, and that is, of course, understandable. They want to protect their children. (Nurse at the Neuro-Intensive Care Unit at Aarhus University Hospital)

Through a design project, we seek to explore how introducing sounds from the hospital ward into the waiting room at a Neuro-Intensive Care Unit can be a helpful tool in facilitating a less stressful visit situation between a child and the hospitalised relative. The project is a response to a growing wish amongst staff at NIA, the Neuro-Intensive Care Unit at Aarhus University Hospital, to motivate parents to bring children to visit relatives, with the understanding that it is important to involve children in the hospital stay of a relative, as they need to demystify the situation – fantasies are replaced by an experience of the actual situation – and they can benefit from being included in the process instead of feeling left out (Heslet 2010). Today, nurses spend much time informing relatives about the importance of this involvement, but more often than not, relatives maintain the belief that the hospital is an environment not suitable for their youngest children. Not only the meeting with a sick relative, but also the context of the hospital keep parents from bringing their children. To understand how we might meet the worries of relatives facing the visit situation, this research investigates what sets the grounds for such scepticism and how we, in a respectful manner, can prepare the visit in order to make it more inviting to bring children. The video below gives an impression of the design context:

VideoObject1: Impression of NIA

NIA represents a typical Neuro-Intensive Care Unit in Denmark where patients are hovering between life and death due to severe head and spine injuries. On the left-hand side of the main corridor is a small waiting room. Visitors often spend hours here, waiting for the right time to visit their relatives in one of the two wards, each holding six beds. The wards are located on the right-hand side of the corridor, each one separated by a glass monitoring room, where 6-8 nurses and doctors constantly monitor the patients. In addition to the ambient noise of conversations, equipment, computers and phones coming from the monitoring room, the soundscape of the wards also includes the constant beeping from up to fifteen alarms per bed, mixed with sounds from equipment that, when handled, can be quite loud. The sounds are not easily differentiated and emerge as a cacophony, difficult to understand for others than the experienced staff. Therefore, the staff emphasises that the soundscape of NIA represents the primary stressor to patients and visitors, as they perceive it as both intrusive and alarming. This experience is supported and documented in several studies made in similar hospital environments, showing how unwanted sound, or noise, is a general problem in the modern hospital (Falk and Woods 1973; Baker 1984; Meredith and Edworthy 1995; Berg 2001; Rice 2003; Busch-Vishniac et al. 2005; Edworthy and Hellier 2005; Ugras and Öztekin 2007; Wainwright and Wynne 2007).

The nurses insist that children who are visiting NIA for the first time should be meticulously prepared for what they are about to experience before entering the ward. Otherwise they might become anxious, or even panic, which inevitably obstructs the aim of the visit. The nurses typically try to demystify the situation in the waiting room by drawing and talking about the hospital apparatus. However, relevant tools are lacking to prepare the children in an appropriate way for the soundscape, as it is difficult to mimic its effect using only words or drawings. This often leaves the children standing, frozen, in the ward, as the unfamiliar sensorial impression inhabits the foreground of their attention, leaving no perceptual room for the meeting. Therefore, in response to this concrete challenge, we initiated the development of the design artefact Kidkit, which invites children to familiarise themselves with the alarming sounds they will face in the ward, through the process of controlling and repeating them in an embodied and socially engaging way, with interactive furniture in the waiting room.

With specific attention for how the multiple sensory inputs of an environment affects the way we feel, behave and interact with others, the notion of atmosphere is presented as the overall theoretical approach when designing a tool to help children prepare for engaging with environments in which the soundscape forms an obstacle for social relations and/or a relaxing bodily state (Thibaud 2011). A focus on atmospheres underlines the impact of these impressions on the people involved, relevant to the view of a hospital setting as a place filled with unfamiliar sense impressions. From a design point of view, the concept of atmosphere is to be understood as a dynamic shift between those factors that might inhabit the foreground of the subject’s attention and which might later inhabit her background awareness. The relations between different states of awareness are essential to the way we habituate ourselves to a place. Habituation is an often-overlooked phenomenon when investigating how humans sense, and cope with, their surroundings (Horowitz 2013: 44). Building upon habituation to atmospheres, ascribing to a dynamic perspective inspired by Henri Lefebvre’s (Lefebvre 2004) concept of rhythm, we introduce embodied sound habituation as design strategy. Exploring how to smooth the way for a faster habituation process within alarming atmospheres, a strategy has been developed through implementing different tactics in the concrete design project, Kidkit.

In a broader perspective, embodied sound habituation represents a design strategy that challenges the growing field of solutions aimed at improving the quality of hospital environments through positive distractions (Hamilton and Shepley 2012: 165). Instead of offering a momentary distraction from the environment, embodied sound habituation aims at imposing a change in the attitude of the user towards an existing situation. Guiding the user to become an integrated and meaningful part of the existing environment is relevant in situations where it is not desirable to be distracted from the social and spatial surroundings, e.g. when interacting with others.

2. Related work

In the current discourse surrounding the planning and building of new Danish hospitals, there has been growing attention as to how the hospital environment and its sensory impressions can have an unintended negative effect not only on patients, but also on staff and visitors (Folmer, Mullins and Frandsen 2012). Several publications appeared concurrently, proposing recommendations as to how hospitals might accommodate more healing and pleasant environments through evidence-based research and design (Frandsen et al. 2009). This approach can be seen as part of a larger international paradigm shift in the design of the modern hospital: from functionalism towards a growing interest in improving the physical environment in such a way that it supports user needs, preferences, and sensibility.

Along these lines, current research in the acoustic arena also addresses various aspects of how to improve the existing hospital environment, e.g. altering room acoustics by decreasing reverberation time (Berg 2001). Researchers addressing human-related factors in alarm design offer an important contribution, with the aim of developing new standards for alarm sounds that are patient- rather than equipment-centred (Edworthy 2000). Building on studies that demonstrate how a typical medical environment is dominated by too many alarms that are "too loud, too insistent, and tend to disrupt thought and communication at the very time that it is vital" (Edworthy 1994: 15), a more ergonomic way of constructing auditory warnings is proposed (Kerr 1985; Stanton 1994; Meredith and Edworthy 1995; Edworthy and Hellier 2005).

In addition to the improvement of the existing physical environment, healing architecture and design introduces a holistic perspective aimed at improving the overall atmosphere, by implementing, for example, art and designed light (Daykin, Byrne, Soteriou and O'Connor 2008).[1] Within the field of lighting design, new studies investigate, with attention for the user’s socio-cultural background as well as knowledge of what homey light might mean to various users, how an atmospheric approach to the quality of light in the hospital ward can be applied to create a model for a pleasurable and variable indoor light atmosphere (Stidsen 2012). However, it is difficult to find similar durable and comprehensive sound design alternatives, which address the shared atmosphere. Strategies such as music therapy and music intervention do not generally address the shared social atmosphere, but focus rather on creating a momentary island of rest for a single patient, precluding interaction with others. Research lacks descriptions of the long-lasting effects of healing music, and it is suggested that the impact of such interventions is limited to short periods of time (Nilsson 2009).

Considering the very nature of atmospheres and the way humans experience the world in a multisensory way, there seems to be an apparent lack of solutions created in an interdisciplinary collaboration. Therefore, we stress that the time is ripe to approach the design of ward interior from a multisensory point of departure.

3. Methodology

In the broad interdisciplinary field of human-computer interaction, referred to as Constructive Design Research, researching through design is the preferred method. A method where the "construction - be it product, system, space, or media - takes centre place and becomes the key means in constructing knowledge" (Koskinen, Zimmerman, Binder, Redstrom and Wensveen 2011: 5). This includes a process of engaging with so-called “wicked problems”, that is, real-world problems extracted from messy situations, with conflicting interests and multiple perspectives that are not reductively solvable (Stolterman 2008). “Wicked problems” are found by studying the world and can be mitigated through the process of design to transform a situation from its current state to a preferred state. The contribution is a novel integration of theory, technology, user need and context (Zimmerman, Forlizzi and Evenson 2007). Thus, the research artefact is designed to elicit new knowledge, in the process of addressing a particular problem (Stolterman 2008).

We initiated and have been responsible for the development of the design project Kidkit as well as the subsequent evaluation among NIA users. In the design process, user studies provided the basis for our design choices. The development of Kidkit has evolved around observations, sound recordings, and photo and video documentation in the ward. We have made walks with nurse commentary in order to capture the atmosphere of the ward. Further, we have conducted interviews with several nurses as well as a psychiatrist regarding children’s behaviour in the ward environment. Moreover, we have continuously tested the prototypes on children. Evaluations of real visit situations, where the nurses introduced children to Kidkit before visiting a hospitalised relative, were conducted.

Kidkit was developed through an interdisciplinary collaboration. While acknowledging the difficulty in extracting and analysing specific aspects of an integrated whole, this article focuses specifically on the sound design aspects, exploring embodied sound habituation as a possible conceptual tool when designing for atmospheres in which sound forms a primary stressor. The final prototype has evolved through an iterative design process, where sketching, modelling, prototyping and user-involvement laid the groundwork for the design choices made. A thorough explanation of the design process and evaluation is presented elsewhere (Kinch and Højlund 2013). Hence, while we leave the comprehensive evaluation data out in this article, relevant field notes (in italics) will appear throughout the article as informative impressions derived from our interviews, observations and evaluations. One specific observation of Kidkit in use is described in detail, as it specifically addresses how our sound design strategy is unfolded in a real life scenario.

4. Developing Embodied Sound Habituation as Design Strategy

The Concept of Atmospheres

Using the concept of atmospheres as our theoretical starting point, we pay attention to the multisensory stimuli of a particular place and try to understand the affective impact of these stimuli on the people involved, a process we found particularly relevant in the hospital setting, filled with new and unfamiliar sensory impressions. The concept of atmospheres addresses the lived experience of people situated in a particular place. According to the German philosopher Gernot Böhme, atmospheres are constantly emerging in-between subjects and objects (Böhme 1993). The atmosphere belongs neither in the sphere of the object nor in that of the subject; rather, it is a co-presence that exists within the terms of the subject/object engagement. The German expression “sich befinden” and Danish “at befinde sig” contains this double in-situ relationship in the sense that they refer to both being somewhere as well as to how one feels about being there (Albertsen 2012: 2). Perception is therefore understood as an embodied and temporal practice. Thus, atmospheres are not static states existing beforehand in a room, but rather an ongoing and temporal negotiation between the sensing body in relation to others and the environment. Therefore, the dynamic unfolding of an atmosphere is a fundamental feature of finding one’s place and thereby making sense of a place over time.

Rhythms - A Dynamic Perspective on Atmospheres

Jean-Paul Thibaud stresses how atmospheres are closely connected to embodied and temporal functions. We do not passively sense an atmosphere; the atmosphere sets the tone of a situation and resonates with the sensing body in constantly shifting consonant and dissonant relationships (Thibaud 2011). In the search for shared words to talk about atmospheres, Thibaud points to metaphors related to sound and music, revealing a common structural relationship to the temporal in both the worlds of sound and atmospheres (Thibaud 2011: 1). Sound and theories of sound and listening could therefore lead to concrete methods of working with the dynamic aspects of investigating and designing atmospheres.

As presented in our article “Designing Dynamic Atmospheres - Highlighting Temporality as Design Concern within Interaction Design” (Højlund and Kinch 2012), the translation of a temporal awareness into concrete parameters operational in a design process presents a challenge, when working with atmospheres, in interaction design. Temporality is often approached either as an unwieldy subcategory of other concepts like space or technology or as something fleeting and outside the body (Højlund and Kinch 2012). Addressing this challenge, we propose an elaborated connectedness of the temporal with the felt body, as atmospheres emerge in resonance with the body. This awareness can help the designer to rethink the temporal as an embodied way of experiencing the production of space and not only consider it as something fleeting outside us.

In his book Rhythmanalysis – Space, Time and Everyday Life, Henri Lefebvre uses rhythms as an analytical tool, describing how “everywhere where there is interaction between a place, a time and an expenditure of energy, there is rhythm” (Lefebvre 2004: 69). Presence is therefore innately temporal in character and can only be grasped through the analysis of rhythm. It is important to note that “rhythm” refers not only to traditional concepts of rhythm related to sound and music, but also as constituting a pervasive phenomenon emerging in the ecology between human and surroundings.

The core concept of listening invites us to listen to the body, buildings, the environment, and so forth, in order to make us more sensitive to times than to spaces (Lefebvre 2004: 22), thereby expanding our awareness of phases, periods, shifts and recurrences. By listening to the temporalities and the shifts of a dynamic atmosphere, we can gain an attentive ear, enabling us to make sense and order of chaos by differentiating the multisensory inputs of the dynamic atmosphere. Attentive listening is obtained through what might be described as a sort of meditational practice, connected to an artistic practice, of engaging with the surrounding rhythms in order to resonate with them in a consonant way. We can only listen to and perceive our surroundings and their rhythms as being fast or slow in relation to other rhythms; and given that we are always in a body, the rhythms of the body are an important reference in our experience of an atmosphere.

This way of understanding rhythm changes the underlying presumption of the perceiver as merely adapting to the tonality of a place, and instead suggests that the atmosphere is not placed either inside or outside, but emerges in the shifting relation between the interconnected rhythms of the self, the other, and the environment. Through maintaining an awareness of these different conceptualisations of rhythms in the design process and by understanding the basic dynamic identity of the atmosphere as being connected to sound as phenomenon, the temporal aspects become parameters accessible in the design process.

Embodied Sound Habituation

I feel that there are two different ways to experience the place [NIA, eds.], because when I have been off for a longer period and come back, the place affects me differently than during everyday work life. After a holiday, I often have this … Gosh, do I really have to go in there? (Nurse at NIA)

Lefebvre’s theory on the meditative process of developing an attentive ear by listening to the rhythms of the world as well as those of the body resonates with the concept of habituation. In positioning our understanding of habituation, Immanuel Kant’s construction of habit, as “a negative counterpoint to the processes of human self-making” (Bennett, Dodsworth, Noble, Poovey and Watkins 2013: 7), is abandoned. Instead, we follow the trajectory of habit and habituation as presented by Gabriel Tarde, who “accounts the roles of suggestion, imitation and repetition in the constitution of the social” (Bennett et al. 2013: 10). Within psychology, habituation is referred to as a basic psychological learning process wherein there is a decrease in response to a sense stimulus after a subject is repeatedly exposed to it, indicating a loss of interest (Berk 2008: 136). Thus, habituation is a natural process, where focus on particular aspects of the environment thus shift into the background of awareness, leaving room for other aspects to inhabit the foreground of attention. Approaching atmospheric experiences from a habituation perspective points towards the observation that the users form no socio-culturally “homogeneous audience” (Albertsen 2012), thus it is a way to acknowledge how our own habitual background continuously shapes our individual and contingent experience of the atmospheres.

Moving into the discourse on sonic environments, Barry Truax stresses how our innate ability to shift sounds to the background of awareness depends on habituation, which involves memory and associations. For our perceptual system to be able to shift specific sounds to the background of awareness, they must be habituated, meaning that they are expected and predictable in a certain context (Truax 2001: 21). This type of background listening demands that we are able to easily detect and separate sounds from each other, so we won’t have to consciously struggle with the environment in order to make sense of it, which can lead to the feeling of being alienated or separated from the surroundings. It is therefore not only the perception of the specific characteristics of the sound that influences whether they are put in the background of awareness, but also the way in which they are habitually perceived (Truax 2001: 22). It is, however, important to stress here that the auditory system is also our most effective alarm system. As we are continually monitoring the sensory background for changes, a sudden auditory change in the environment will trigger an automatic startle reflex that is most likely to redirect an unexpected stimulus to the foreground of attention, making it impossible to ignore (Horowitz 2013: 111).

Thibaud underlines the importance of reflecting not only on the different categories of listening but also how, and under what conditions, we manage to shift from one type of listening to another (Thibaud 1998: 2). A design that responds to actively changing listening modes requires an alternative sound design strategy, however, not by redesigning the concrete sounds in the environment or by covering them, but instead by altering the attitude of the users towards the existing sonic environment. For the designer to induce such a change, through facilitating user coping with complex and alarming atmospheres, an understanding of how to influence the autonomous and conscious habituation processes for environmental sounds is needed.

By acknowledging habituation’s connectedness to rhythms and resonances as a fundamental and dynamic quality inherent in finding one's place, we underline once more that atmospheres emerge as rhythms in-between the body and its surroundings through an ongoing temporal negotiation. Embodied sound habituation as design strategy invites the user to develop an attentive ear through controlling prominent rhythms of the environment in an active and embodied way and becoming capable of synchronising them with her own bodily rhythms. The users now become co-creators unfolding the atmosphere. The habituation process is actively aided, guided and accelerated by a design artefact. The advantage of designing specifically for this process is that the habituated sounds can move to the background of awareness, leaving perceptual room to what the user wants to take the foreground of attention, here the meeting with the relative.

5. The Design Case Kidkit

Context & Problem

A daughter of a patient with head injury explains how her mother told her that she thought she died several times while slowly waking up from an unconscious state in the hospital. She later explained that this experience was triggered by the alarm sound from another bed in the shared ward. She associated this sound with that of a heart monitor stopping as she remembered it from movies. (Højlund and Kinch, field notes)

Building upon field work and interviews with patients, anthropologist Tom Rice describes the hospital as a holistic entity with an “unusual atmosphere of sensory absences” (Rice 2003: 5) – caused by the lack of tactile, visual and olfactory, among other, stimuli – leading to a sense of alienation and detachment from the surroundings. These sensory absences often cause the soundscape of the hospital to shift to the foreground of attention, making hearing one of the most important senses for understanding and making sense of the environment. This resonates with statements from the nurses at NIA, in which noise is said to be the main stressor. In initial stages of the research, one of the nurses stated that her biggest wish was that someone would design a noise deflector that could create a private atmosphere for the patients and relatives in the shared wards.

The soundscape of this unit, as is often experienced in modern functionalistic hospitals in general (Frandsen et al. 2009: 71), is dominated by a cacophony of alarms and other functional sounds relevant for specific members of the staff. As they are not relevant or functional for the patients, they become unwanted noise for them. Because the alarming sounds are designed to arouse and attract attention, they are difficult to ignore and resist being shifted to background awareness, and thus interfere with patients’ attempts to sleep, interact, or relax. Combined with other sounds from, for example, equipment and conversations, they form a complex soundscape with many intrusive sounds, intensified by long reverberation times related to the acoustic properties of hard tiled walls and floors. This soundscape induces unnecessary anxiety and aroused body states, counteracts healing and sleeping, and augments the feeling of seclusion and alienation from the environment.

After being prepared through a verbal explanation in the waiting room, two brothers, seven and five years old, enter the ward to meet their hospitalised mother for the first time following her accident. The nurse explains that the two kids feel ill at ease when entering the ward and that “both of them are standing at a remarkable distance from the bed. Neither of the boys moves closer when the mother extends her hand”. The nurse believes that they are frightened and that this is why they approach their mother as a stranger. Afterwards the nurse says that she believes “that this visit was not, by any means, successful for anyone”. (Højlund and Kinch, field notes)

Nurses stress that children brought to the unit must be meticulously prepared in the waiting room for what they are about to experience, in particular concerning the many alarming sounds in the ward. The sudden shift in atmosphere from waiting room to ward often becomes an obstacle for an engaged meeting with the relative. The actual change in atmosphere itself becomes the foreground of attention, even though all parties would prefer this to remain in the background. In such a situation, the rhythms of the alarming atmosphere in the ward affect the bodily rhythms of the child, which leads to a feeling of stress in response to aroused bodily rhythms. Our main design challenge has been to find an adequate response to this invisible obstacle between child and environment.

Form & interaction

Figure 1: Kidkit in five different stages during a visit at the NIA

Kidkit is flexible interactive furniture, which accompanies the children and nurse throughout a visit: from the waiting room, to the ward, and back again. Its flexibility allows for change in form, and its interaction corresponds to the specific functions it serves during the different stages of the visit. Kidkit is designed with the overall rhythm and structure of the visit in mind: First, Kidkit assists children through the entire visit, becoming a secure anchor that can detract focus from the sudden shifts in atmospheres, thus helping the children become more sensitive to time than to spaces. Second, the temporal design allows for adaption to specific rhythmical functions, appropriate to the different environmental settings. Taking these aspects into account, the bodily rhythms of the children adapt in relation to their habituation process, as described below. We thus present different design tactics relating to specific stages of the visit:

VideoObject2: Kidkit in use

Figure 2: Transformations of Kidkit

a) When Kidkit is introduced to the user in the waiting room for the first time, it is in the form of five upholstered blocks, stacked into two piles, the upper block of each of the two piles being flexible. Kidkit is designed to afford two occupants (child and adult) a surface to sit on, at eye-level with each other, accommodating an intimate atmosphere. A touch interface with eight sound triggers (explained in detail in the next section) is sewn onto the surface of the upper, green, block of Kidkit.

VideoObject3: Kidkit sound triggers

b) When the users are ready to go into the ward, the wheels of Kidkit are revealed by means of a handle, thus making it possible to lift and lower the furniture and wheel it from one space to another. The mobility of Kidkit allows the child to bring something to which she is habituated into the ward, encouraging her to take ownership of Kidkit before, during, and after the visit as a familiar anchor in a confusing and unknown environment.

VideoObject4: Kidkit wheeling

c) The flexibility of the form allows the child to alter the form from that of a seat to a stairway configuration when placed by the bedside in the ward, assisting her to stand, at eye-level, beside the hospitalised relative. The physical, bodily, way of interacting with Kidkit, through rhythmic folding and unfolding manoeuvres, invites the child to create meaning through embodied interaction.

VideoObject5: Kidkit unfolding

The colours support the various transformations of Kidkit. In the waiting room, where it serves as a tool for playful exploration, Kidkit exhibits strong colours. In the ward, in the stairway configuration, the sound triggers are hidden, and its most visible colours are in the grey scale, so as to attract less visual attention. The simplicity of the quadrangular shapes of the five poufs is similar to building blocks, and the shape of Kidkit, corresponding to the scale of a child’s body, allows for flexible play practices. We emphasize that Kidkit is not a handheld device, but furniture that physically relates equally to body and space, affording collective use. In this manner, Kidkit initiates a shared transitional space, for the child, the other relatives, and also for the nurse, assisting them with coordinating the visit (Kinch and Højlund 2013). Furthermore, the size and materiality of Kidkit challenges the child to be physically engaged, moving focus away from the sudden shifts in atmospheres.

Sound Design

Figure 3: A seven-year-old brother visiting his sister at NIA

Magnus, a seven-year-old boy is going to visit his hospitalised sister who has a brain tumour. In the waiting room he meets Kidkit and pushes one button at a time, triggering the sounds. When he asks, ”Can these sounds be heard by Julia right now?” the nurse answers, ”No, the sounds around Julia are coming from the equipment and the two other patients. The equipment is noisy because it wants the nurse to look at it. It does not make noise because the patients are in pain”. This conversation gives the boy insight into the sounds of the apparatus, and after this conversation, he and the nurse decide to go and see Julia. Upon entering the ward and during the meeting, Magnus is focused on his sister. He appears relaxed and tells stories. Afterwards, when we are in the waiting room, we ask him about the alarming sounds in the ward, but he says that he did not notice them at the time. We then asked him if he thinks he heard any of the sounds from Kidkit introduced earlier in the ward. He answers, “Yes, I heard the funny dododododo sound”, and he repeats it in a rhythmic pattern similar to the sound from the Kidkit, which was sampled from one of the alarm sounds in the ward. (Højlund and Kinch, field notes)

Following the specific sound design focus presented in this article, Époché is implemented as a tactic to design for embodied sound habituation in the waiting room. Époché refers to a practice presented by Pierre Schaeffer (reworked by Michel Chion). Adapted from a phenomenological understanding of how the bracketing of a phenomenon can open up a method to examine it aside from one’s associated assumptions and beliefs, the concept refers to the process of putting specific sounds in parentheses in order to actively create reduced listening circumstances (Chion 2009: 28). Reduced listening can change listening from serving as a vehicle of meaning concerning the source, asking us, instead, to listen to the sound itself. By isolating or moving the sound from its source and out of the audio-visual complex to which it initially belonged (what Schaeffer calls acousmatic listening) and listening to it repeatedly, one can actively recondition one’s habitual listening patterns and references. This will allow “us to clarify many phenomena implicit in our perception” (Chion 2009: 31). Although the most natural mode of listening is to try and understand the sound by identifying its source, this repeated reduced listening can “perhaps ‘exhaust’ this curiosity and little by little impose ‘the sound object as a perception worthy of being listened to for itself’” (Chion 2009: 12).

Époché, through repeated reduced listening, can set the ground for habituating sounds quickly, thus changing the attitude towards them, e.g. through developing a more musical perception in the waiting room. This tactic is unfolded by presenting the eight sounds separately from each other. One button triggers one sound file as feedback, made with touch sensors and a phidgets board. Hidden beneath the upholstery, a computer and loudspeaker play the sounds that have been sampled directly from the ward. These sounds are based on a one-hour recording made in the ward - where the nurses presented all sounds they found dominating, not only alarm sounds, but also noises made while handling equipment - that were thought to be suitable for sampling. The duration of the different sound files is two seconds, maximum, and the sounds are categorised into three groups: yellow areas play three different alarm sounds, red areas play two suction sounds from a respirator, and the blue areas play three dominating equipment sounds, e.g. the lid of a bin being shut. The characters of the eight sounds are quite different in pitch, timbre, rhythm, and expression. The feedback is immediate and can be triggered again and again when pushed, and the system can play several sounds on top of each other if more than one trigger is activated. In this way the child is able to create a rhythmic pattern corresponding to well-known beat structure, resembling a drum loop with various drums, and thus conditioning a musical interpretation of the sounds.

The embodied experience of controlling the concrete rhythms of the environment repeatedly in one’s own tempo can help children to synchronise the sounds with their own bodily rhythms. In this way, the alarming sounds can be shifted to background awareness upon entering the ward, as they are now habituated as familiar, expected, and predictable in the context rather than frightening and uncontrollable.

Magnus’ interaction with Kidkit indicates that he habituated the “dododododo” alarm sound anew and could separate it from the rest of the sounds in the ward.

The way he repeated the sound, rhythmically and melodically as in the sound sample, and referred to it as funny indicates that the strategy of embodied sound habituation through Époché in the waiting room helped him transform his perception of the sound into something primarily musical and not frightening. Furthermore, his statement that during the visit in the ward he did not really notice the sounds indicates that he was able to put the alarming atmosphere in his background awareness, leaving room for the visit to take the foreground of attention.

6. Concluding Remarks

When acknowledging the dynamic habituation process of atmospheres as an essential part of finding one’s place and of feeling as an integrated part of an environment, it is important to reflect on how different contexts and different target groups call for different strategies in the search to help this process through design. In calm and familiar surroundings, the rhythms of the body can adapt more easily to the rhythms of the environment (Horowitz 2013: 189), and therefore a more traditional approach to atmosphere design, as in a traditional stage setting, could be effective (e.g. through slowly changing colours, lighting candles, or playing calm background sounds). The claim presented throughout this article is that slow and calming rhythms presented to visitors in an alarming atmosphere would not be felt to be in coherence with the predictably aroused and tense bodily state and rhythms. Therefore, it would be ineffective in synchronising the rhythms of the environment with the rhythms of the visitor.

Habituation typically happens almost automatically in environments where we spend a lot of time, through a gradual and slow adaption. As a patient in an English hospital puts it: “Well, I guess as with whatever environment you become familiar with, you gradually lose the acute sensation that you first get. I mean, you can really be overwhelmed with the noises … Gradually, that fades, and you can almost not notice it.” (Wainwright and Wynne 2007: 14). In the brief time of a short visit to an alarming atmosphere, this process cannot take place. Experiences derived from our case study indicate the positive effects of an active and engaging habituation process, which set the ground for a quicker habituation process. In an environment where sound is one of the main stressors, we therefore suggest a strategy based on embodied sound habituation. The user is given an opportunity to not only listen to differentiated sounds derived from a chaotic soundscape, but also to control them through embodied gestures, to synchronise them with her own rhythm, and be able to shift them to background awareness when faced with more important tasks.

Looking at existing solutions, which can be primarily seen as implementing positive distractions, through the lens of dynamic atmospheres as presented throughout this article, at least two insights are of paramount importance:

A hospital is not one uniform place with one type of static atmosphere. Calming music, art, and lights are only relevant and useful in specific atmospheres, at specific periods of times, namely the ones where people are capable of taking in calming and gentle impressions.

Existing solutions mostly aim to improve the well-being of the individual patient through tactics such as diverting focus from certain aspects, those which seem undesirable or unpleasant, of the surrounding atmosphere and bodily presence, with the unfortunate result that communication and interaction with others actually becomes more difficult. By designing solutions aimed at the shared social atmosphere, other groups in addition to the patients are also be considered.

Our contribution, therefore, has been the articulation of a design strategy that does not try to create a temporary distraction, but acknowledges the basic need of the user to feel that she is an integrated part of the environment, resonating with the surroundings in a consonant way. This strategy might be relevant in other alarming contexts and with other target groups, but this would require more testing and evaluation to insure the durability of the proposed strategy in future work.

7. Acknowledgements

We would like to thank the Neuro-Intensive Care Unit at Aarhus University Hospital, most prominently Lone Moeslund and Helene Bugge, for kindly letting us into the ward and for participating in this research. Also, thanks to our colleagues Niels Albertsen, Morten Breinbjerg, Susanne Højlund and Helle Karoff for valuable discussions and feedback. And finally, we thank the Alexandra Institute A/S for sponsoring the materials for Kidkit and, in so doing, making this research possible.

Marie Højlund is a composer and sound artist currently undertaking a PhD in Audio Design at The Department of Aesthetics and Communication at Aarhus University, Denmark. In her practice based research Marie is particularly interested in exploring different strategies to create dynamic atmospheres with sound integrated into the physical environment or placed as sounding installations in the open public space.

Sofie Kinch is an architect and industrial PhD Fellow at Aarhus School of Architecture and the Alexandra Institute Ltd., Denmark. In her research, Sofie is particularly interested in the notion of designing for changing atmospheres within the field of Interaction Design and derives her research results through practice-based design approach.

Daykin, Norma, Ellie Byrne, Tony Soteriou and Susan O'Connor (2008). “The Impact of Art, Design and Environment in Mental Healthcare: A Systematic Review of the Literature.” The Journal of the Royal Society for the Promotion of Health 128/2: 85-94.

Zimmerman, John, Jodi Forlizzi and Shelley Evenson (2007). Research Through Design as a Method for Interaction Design Research in HCI. CHI ´07. Proceedings of the SIGCHI Conference on Human Factors in Computing Systems (pp. 493-502). New York: ACM.